Outpatient CT Referral Form Referring Veterinarian’s information Referring Date Referring Veterinarian Clinic Name Phone (###) ### #### Email Preferred method of communication Phone Email Client/Patient information Owner's Name First Name Last Name Owner's Phone Number: (###) ### #### Owner’s email Patient’s name Species Sex Male Female Spayed Neutered Age Breed Weight Tentative Patient Diagnosis Reason for CT CT scan site Head Thorax Abdomen Limb LF Limb RF Limb LR Limb RR Other Other Brief description of the patient’s history/comorbidities and current medications: (Please attach a copy of the medical record and all relevant diagnostics) Patient blood work (CBC/Chem) must be completed within 2 weeks of the CT scan Any known allergies, medication or anesthesia reactions? Risks of anesthesia and contrast administration have been discussed with your client prior to referral. Thank you!
